Medication Administration Error Due to Obstructed View
Penalty
Summary
Armstrong Rehabilitation and Nursing Center was found to be non-compliant with professional standards of care as per 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The deficiency was identified during an abbreviated survey following complaints, where it was discovered that a resident, admitted with diagnoses including influenza, resistant hypertension, and weakness, was mistakenly administered medication intended for her roommate. The error occurred because the Registered Nurse (RN) responsible for medication administration did not realize there were two residents in the room due to a pulled curtain obstructing her view. The RN administered medications that were not prescribed to the resident, including amlodipine besylate, furosemide, and potassium chloride, which were intended for the roommate. The incident was documented in the resident's progress notes, and both the family and physician were informed. The resident confirmed the medication error during an interview, describing the event as "scary" but stated she was fine afterward. The Nursing Home Administrator acknowledged the facility's failure to meet accepted standards of practice.
Plan Of Correction
R1 suffered no adverse effect from receiving R2's meds for 1 dose. R1 was interviewed and offered counseling services. Whole house audit completed to ensure no other residents received incorrect medication. Care plan reviewed for R1. Education on medication administration provided to nurses by DON or designee on or before 2/14/2025. Audits will be conducted on medication passes on 4 nurses weekly by NHA or designee weekly x 4 weeks and monthly x 1 month.